OAR 436-040-0030
Application for Determination of Relief From the Workers with Disabilities Program
(1)
The paying agency must provide the director adequate evidence to establish eligibility for determination of relief from the Workers with Disabilities Program.(2)
When the deductible has been met and possible eligibility for relief becomes known, the paying agency shall make prompt application to the division requesting determination of relief from the Workers with Disabilities Program in a form prescribed by the director.(3)
The application shall be submitted prior to the date of the last valuation affecting an employer’s experience rating, prior to the last valuation for retrospective rating, whichever is the last to occur and prior to the employer ceasing to do business. The application shall be supported by sufficient evidence establishing eligibility for reimbursement under the general provisions herein and in accordance with OAR 436-040-0010 (Criteria for Eligibility). For employers that are not experience rated, application shall be submitted prior to the date there would have been a last valuation, had the employer been so rated, and prior to the employer ceasing to do business. The preceding application time frames do not apply to self-insured employers or their paying agencies.(4)
To meet the requirements of OAR 436-040-0030 (Application for Determination of Relief From the Workers with Disabilities Program)(3), the paying agency shall:(a)
Specify the condition which caused permanent impairment and which constituted a handicap;(b)
Specify whether this request is based on a causal or contributory relationship pursuant to OAR 436-040-0010 (Criteria for Eligibility)(1)(c);(c)
Provide documentation describing prior impairment: such as medical reports, direct information from the worker, employer documentation, prior Determination Orders, Opinion and Orders, and Orders on Review;(5)
The division will review the application to assure it is complete and the $1,000 deductible has been met. The application, supporting documentation, and claims involved will then be submitted to the division for an eligibility determination.
Source:
Rule 436-040-0030 — Application for Determination of Relief From the Workers with Disabilities Program, https://secure.sos.state.or.us/oard/view.action?ruleNumber=436-040-0030.